Hypodontia | OPEN

cLINIcAL

Restorative dentistry clinical decision-making for

hypodontia: peg and missing lateral incisor teeth
Sean Dolan,1 Gareth Calvert,2 Lynnsey Crane,2 Lee Savarrio2 and Martin P. Ashley*3

Key points
Understand the decision-making process for Understand the decision-making process for peg Understand the decision-making process for
managing missing lateral incisor teeth. lateral incisor teeth. missing lower incisor teeth.

Abstract
Peg-shaped and missing lateral incisor teeth are common features for patients affected by hypodontia. While
improvements in dental appearance may be a strong motivating factor for these patients, providing dental treatment
to improve the clinical condition and achieve an acceptable and stable outcome can be complex and lengthy.
For patients affected by hypodontia, discussion and consideration of various approaches to their individual treatment
are best achieved in a multidisciplinary team environment. This allows debate of options and joint agreement
between at least orthodontic and restorative dentistry specialist colleagues, based largely on clinical factors, towards
a treatment plan that is acceptable to the patient. As most patients with this lateral incisor form of hypodontia are
initially treated as teenagers and young adults, there is also an understanding that treatment outcomes will have
lifelong maintenance and resource implications to consider.
This paper identifies and discusses the key clinical features that influence the treatment planning process for a
patient with either missing or peg lateral incisor teeth. These will often involve consideration of whether to open or
close the lateral incisor spaces and whether to restore or replace a peg lateral incisor tooth. The process should be
patient-centred, evidence-based, and aim to minimise the lifelong treatment burden, retaining options for future
maintenance and retreatment.

Introduction
Around 1.7% of the population are affected by
hypodontia of their upper lateral incisors and
around 0.25% do not develop their lower lateral
incisors.1 For patients affected by hypodontia
who are missing one or more of these teeth,
these issues and the position and shape of their
other natural teeth may have a significant impact
on their dental appearance and often results
in them seeking dental treatment. In the UK,
1
Post DCT Fellow, Glasgow Dental Hospital and School,
Department of Restorative Dentistry, Glasgow, G2 3JZ,
UK; 2Consultant in Restorative Dentistry, Glasgow Dental
Hospital and School, Department of Restorative Dentistry,
Glasgow, G2 3JZ, UK; 3Consultant in Restorative Dentistry,
University Dental Hospital of Manchester, Manchester,
M15 6FH, UK.
*Correspondence to: Martin P. Ashley
Email address: martin.ashley@manchester.ac.uk
Refereed Paper.
Submitted 1 July 2023
Revised 29 August 2023
Accepted 30 August 2023
https://doi.org/10.1038/s41415-023-6330-7
the Association of Consultants and Specialists
in Restorative Dentistry (RD-UK) have three
clinical excellent networks (CENs), within
which colleagues with interest in managing
patients with specific conditions (hypodontia,
cleft, and head and neck cancer) collaborate to
reduce variation and improve patient outcomes.
The hypodontia CEN has over 40 consultant
members, with over 500 years collective
experience gained while managing over 30,000
hypodontia patients. This paper is informed by
the work of the RD-UK hypodontia CEN.
Within this paper, where the term ‘patient’ is
used, this means ‘patient in conjunction with
their parent or guardian’ when appropriate,
especially for the younger patient.
Missing upper lateral incisor teeth
The decision-making process
When treatment planning for patients with
missing lateral incisors, the main aim is to
achieve an acceptable dental appearance, by
providing the patient with a replacement for
their missing teeth. This is achieved by either
orthodontically closing the spaces and moving
other natural teeth into these positions,2,3 or
alternatively by orthodontically creating ideal
spaces and placing restorations into the spaces.
Various general and clinical factors influence
this decision-making process and should be
considered when treatment planning each
patient.4,5,6,7,8
General treatment planning
considerations
The aim of any intervention in hypodontia
patients is to achieve an outcome that is
attractive, functional, healthy, reliable and
financially acceptable, in both the short- and
long-term.
General factors, such as the patient’s
age at presentation, diet and dental health,
cooperation for treatment, cost of treatment
and contemporary evidence-based practice
must be taken into consideration when
planning treatment, with a patient-centred
approach. There are occasions when these

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Table 1 Key clinical factors that influence decision-making for missing lateral incisor teeth

Clinical factor Space opening Space closing

Facial – related

Skeletal classification A Class II skeletal profile may be made worse by space opening A Class III skeletal profile may be made worse by space closing

Buccal corridor and dental Space opening may improve the width of the smile filling the Space closure may narrow the width of the smile creating an
aesthetics buccal corridor aesthetic compromise

Dental – related
A Class II incisal relationship would be made worse with space A Class III incisal relationship would be made worse with space
Incisal classification
opening closure
Centre line The maxillary centre line is usually displaced to the side with the missing tooth9
Canine is either already close to the correct Class I canine
Canine position position, or is mesially inclined, with root apex in distal Canine is already close to the lateral incisor position
position
Tooth – related
Maxillary canine is comparatively large in mesio-distal Maxillary canine is comparatively small in mesio-distal
Canine size dimension, bulbosity and incisal tip to the central incisor and dimension, bulbosity and incisal tip that is in harmony with the
proposed lateral incisor dimension central incisor and proposed lateral incisor dimension
Canine Shade Shade of canine is notably different from the central incisor Shade of canine is similar to the central incisor
Maxillary first premolar is comparatively small in mesio-distal Maxillary first premolar is comparatively large in mesio-distal
First premolar size dimension, length and gingival zenith position, and unsuitable dimension, length and gingival zenith position, and is suitable
to replace the repositioned canine tooth to replace the repositioned canine tooth
Excellent quality and quantity of palatal enamel, allowing Limited quality and quantity of palatal enamel, limiting
Enamel quality and quantity
bonding of a resin-bonded bridge bonding of a resin-bonded bridge

would either impact on whether any treatment

is required or influence the decision of
when to commence treatment, potentially
deferring this to a more appropriate time. In
addition, other orthodontic issues, such as
deep overbites, asymmetries, impaction and
transposition of teeth, will also complicate
potential treatment plans.
Timing of treatment phases is important
when planning for hypodontia, especially with
regards to providing restorations to replace
missing lateral incisor teeth. The precise
orthodontic development of space between
the adjacent central incisor and canine teeth
will allow restoration with either resin-
bonded bridges or dental implant crowns.
However, these treatments are unlikely to be
possible until the late teenage years for bridges
and possibly even later for dental implants.
If orthodontic treatment is commenced and
therefore completed much earlier than this,
the patient will need to use removable retainer
prostheses for an extended period of time. This
may negatively impact their oral health and
challenge patient compliance. If the patient
either has further dentofacial development,
or fails to use the retainer appropriately, the
initial orthodontic outcome will relapse and
treatment will need to be repeated before the
definitive restorations can be provided. For
some patients who complete orthodontic
Fig. 1 Two cases showing orthodontic space closure for missing upper lateral incisor teeth,
with substitution of the canine teeth into the spaces. The canine teeth were both modified to
improve the appearance. a) The repositioned and restored upper canine are probably too large
and the adjacent first premolar teeth too small to contribute to an ideal aesthetic outcome. b)
Comparing this to panel a, the relative sizes and positions of the upper anterior teeth are more
harmonious and create an acceptable outcome. The first premolar teeth have been slightly
mesio-labially rotated and the roots positioned, to mimic the canine eminence
treatment at a young age, a Rochette-design Figure 1 includes two cases, illustrating
resin-bonded bridge, that is often easy to different outcomes for space closure.
remove, could be considered as a provisional The decision-making process, based
restoration. on orthodontic and restorative dentistry
contribution to treatment provision, is
Clinical treatment planning considerations summarised in Figure 2.
There are many clinical factors that may
impact on the decision-making process for Orthodontic retention
missing upper lateral incisors, but those that
commonly occur and are most important As orthodontic treatment may move teeth from
to consider, can be grouped into facial-, stable and unattractive positions to a less stable
dental- and tooth-related factors. The key and more attractive arrangement, retention is
clinical factors relevant to decision making of significant importance, especially during the
are summarised in Table 1. management of patients with missing lateral

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2. The removable Hawley retainer is designed

Fig. 2 The decision-making process based on orthodontic and restorative dentistry
contribution to treatment provision for patients with missing upper lateral incisors
Space opening
Tooth movement required?
Yes
Orthodontic treatment
To open lateral incisor space,
optimising position of other
adjacent and opposing teeth
Orthodontic retention
and provisional tooth
replacement
Restorative dentistry
Prosthetic lateral incisor
• Resin-bonded bridge
• Dental implant crown
Orthodontics and restorative dentistry
Acceptable restorations and retainers, stable tooth positions
Space closing
Tooth movement required?
No No Yes
Orthodontic treatment
To close residual lateral incisor
space, repositioning other
adjacent and opposing teeth
Orthodontic retention
Hawley/pressure-formed
retainer incorporating acrylic
teeth +/1 bonded retainer
Restorative dentistry
Modification of canine+/1 other
teeth to create acceptable
outcome, if required
with one or more prosthetic teeth to maintain
and provisionally restore the lateral incisor
spaces, before the definitive restoration is
placed. As there is a risk of the acrylic tooth
fracturing off the retainer, the adjacent
teeth will then be unretained and the lateral
incisor space will reduce. The ideal Hawley
retainer design should therefore include a
modification, with wire stops placed on each
side of the lateral incisor space, to retain the
central incisor and canine teeth (Fig. 3)
3. A removable, vacuum-formed retainer
is provided as soon as possible after the
restorations are placed
4. If resin-bonded bridges are used, the
restoration design can either contribute
positively to the retention process or lead to
unwanted tooth movements. Orthodontic
treatment that has approximated the upper
central incisor teeth or distalised and
rotated the upper canine teeth can relapse,
with separation of the central incisors and
exaggerated rotation of the resin-bonded
bridges, supported by the upper canine
teeth (Fig. 4a, b, c). This can be prevented
by using both upper central incisor teeth as
bridge abutments (Fig. 4d, e)
5. If the canine teeth must be used as bridge
abutments, a modification of the mesial
surface of the pontic can reduce the risk of
rotation (Fig. 5).

Restoration of lateral incisor spaces

Fig. 3 a, b) The modified Hawley retainer. The prosthetic lateral incisor teeth had fractured
off the retainer, but the additional anterior stops have prevented unwanted relapse of the
adjacent central incisor and canine teeth
incisor teeth, both before and after restorations
are provided.9,10,11
Guidance around retention for these
patients is:
1. Use a removable, rather than a fixed
retainer in the arch that needs teeth
replacing, if resin-bonded bridges are
to be used. The composite resin used to
hold the fixed retainer contaminates the
palatal enamel and surface preparation
is required before the bridge can be
provided. In addition, a bonded palatal or
lingual retainer will need to be removed
before an impression can be made for a
bridge. The previously retained teeth will
then have much less retention during the
period when the bridge is constructed,
with a likelihood of unwanted tooth
movement and the bridge subsequently
not fitting
The restorative dentist and patient will discuss
the various treatment options for replacing
the missing upper lateral incisor teeth.12
With the development and improvements in
resin-bonded bridges and dental implants in
recent decades, it is now unusual to consider
removeable partial dentures and conventional
bridge techniques for these patients.
Both resin-bonded bridges and dental
implant crowns provide patients with a
definitive, fixed prosthetic solution. In general,
orthodontic treatment will have positioned
the adjacent and opposing incisor and canine
teeth, to allow both bridges and implants to
be considered, depending on clinician and
patient agreement. If the spaces are less than
7 mm wide in the coronal areas or the roots of
the adjacent teeth converge to a separation of
less than 7 mm, a dental implant restoration is
unlikely to be possible.
Both resin-bonded bridges and dental
implant crowns provide a bespoke ceramic
prosthetic tooth. A bridge can be delivered in

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as few as two appointments with no need for

operative intervention and does not preclude
future dental implant treatment if required.
The cost of initial and further retreatment is
relatively low, and retreatment, when required,
is reasonably uncomplicated. The perceived
limitation of bridges, that they can debond
unpredictably, is possibly more due technical
design, clinical technique and case selection,
rather than related to an inherent problem
with this treatment. When used appropriately,
resin-bonded bridges have good long-term
outcomes.13,14,15
Dental implant treatment requires more
appointments, delivered over a longer period
of time, with surgical intervention and higher
initial treatment and retreatment costs. The
dental implant itself should provide many years
of security for the crown restoration. In time,
the patient may recognise that their natural
teeth no longer match the crown and request
that this is improved with more treatment. The
time period is likely to be the same for a resin-
bonded bridge requiring replacement.
The clinical and technical aspects of tooth
replacement for hypodontia patients are
Fig. 4 a, b, c) Replacement of missing upper lateral incisor teeth with cantilever resin-bonded
covered in more detail in other papers in
bridges, supported by the canine teeth. Orthodontic relapse of the canine and central incisor
this series. teeth has caused exaggerated rotation of the bridge pontics. d, e) Replacement of the two
bridges with a single-casting, bilateral cantilever bridge. Without further orthodontic treatment,
Peg-shaped lateral incisors the proportion of the new pontic teeth is not ideal but an improved outcome was achieved
Teeth commonly affected by hypodontia
(lateral incisors, second premolars etc) can
also develop as a microdont form. The affected
upper lateral incisor tooth is often described
as a ‘peg’ lateral and it can be assumed that
the development of these teeth is in some way
linked to the process that leads to complete
agenesis of a lateral incisor tooth.
Peg laterals present in a variety of forms,
unilaterally or bilaterally, with or without
a small root but always with a small crown.
They usually impact on the patient’s dental
appearance and therefore are considered in
the decision-making process when planning
treatment.
Fig. 5 Modification of the mesial surface of the pontic tooth, with an extension of ceramic just
The clinical team will assess some key
onto but not bonded to the adjacent tooth. This reduces the chance of rotation relapse of the
factors related to the tooth size and position,
canine tooth position, if used to support a resin-bonded bridge
as part of the decision of whether to either
keep the peg lateral (requiring orthodontic
movement and restoration) or to lose it.16,17 The key clinical factors are summarised in • The lateral incisor space widths are both
If the peg lateral is large enough to restore, Table 2. narrower than ideal when compared to the
it is usually also of sufficient size for an Figure 6 illustrates a patient presenting with adjacent teeth
orthodontic bracket to be placed. When it is bilateral peg lateral incisor teeth, with many of • The gingival zeniths are both lower than
appropriate to lose the peg lateral, this then the features that require consideration in the ideal when compared to the adjacent teeth
leads to a second decision, of ‘space open or decision-making process: • The teeth are displaced palatally, allowing
space close’, as otherwise considered for a • The teeth are small and have a negative restoration of both the labial and proximal
missing lateral incisor tooth. impact on the dental appearance surfaces

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and molar) almost always develops but

Table 2 The key clinical factors to consider when deciding on whether to either keep and
restore or lose and replace a peg-shaped lateral incisor tooth the subsequent teeth are more commonly
missing, it is reasonable to conclude that
Clinical factor lower central incisor teeth rarely fail to
Width at cervical margin. That it does not require a restoration develop in isolation. Therefore, the clinical
When positioned in the Or
presentation of missing lower central incisors
middle of the lateral incisor That it is within 3 mm of the ideal width of the planned lateral incisor space
space, the tooth should be to allow appropriate restoration without creating overhanging margins or an and present lateral incisors may occur because
of sufficient mesio-distal overly triangular shaped tooth the central incisors develop and erupt into the
width... And
The space is equal to the other upper lateral incisor tooth, up to 7 mm wide, lateral incisor positions. This is often of little
depending on the width of the adjacent upper central incisor and canine teeth. consequence clinically, as central and lateral
Length. That it does not require restoration lower incisors are such similar shapes.
The tooth should be of Or Lower incisor teeth are the smallest of the
sufficient length... That it is within 3 mm of the final desired length, sufficient to support a
bonded ceramic restoration permanent dentition and can also be affected
Or by microdontia, although the term ‘peg
That periodontal crown lengthening surgery can reposition the immature lateral’ is not used for lower teeth. However,
gingival margin without exposure of the tooth root.
the number, size and position of lower
Height. The zenith of the gingival margin is 1mm lower than those of the adjacent
The tooth should be upper central incisor and canine tooth. incisor teeth that do develop is so varied that
positioned so that... it can require careful treatment planning and
Bucco-palatal position. The labial surface is level with the adjacent upper central incisor tooth if the delivery to ensure an acceptable outcome.
The tooth should be proximal surfaces need restoring In addition, the inter-canine width and
positioned so that... Or
The tooth is displaced palatally if the labial and proximal surfaces both need the overjet and overbite relationships will
restoring. also determine the dimension and indeed,
Occlusal relationship. Without contacting the opposing lower anterior teeth the number of incisor teeth present when
There should be sufficient And treatment is completed.
inter-occlusal space to With the incisal edge level with the other upper lateral incisor tooth
restore the tooth... And For these patients, as the alveolar ridge
With the incisal edge 1 mm higher than the adjacent upper central incisor tooth. is so underdeveloped in the positions of
the missing teeth, it is rarely appropriate to
consider dental implant placement 18 (Fig. 7).
The inter-radicular space is narrow and
even with bone grafting procedures to
augment the surgical site, the long-term
stability and outcome of lower incisor dental
implants in the hypodontia patient, can be
poor (Fig. 8).
Therefore, orthodontic positioning of
the lower anterior teeth to optimise the
use of a resin-bonded bridge is required.
The relatively small enamel surface
area for bonding and the relatively thin
and translucent incisal edge need to be
considered when the lower incisor tooth
positions are agreed.
Generally, if only one lower incisor tooth
Fig. 6 a, b, c) Bilateral peg lateral incisor teeth, with the case illustrating a number of key is missing, the ideal orthodontic outcome
features requiring consideration as part of the decision-making process would be to create a single space adjacent to
the canine tooth. If two lower incisor teeth
are missing, the ideal outcome would be
• The teeth cannot be restored to an ideal Lower incisors to create either a single or a double width
length without contacting the opposing Missing or diminutive lower incisor teeth space in the midline between two incisor
lower anterior teeth. are a relatively common finding for patients teeth. This space can be restored with a
with hypodontia of other teeth. Although resin-bonded bridge.
These teeth should either be orthodontically missing lower central incisor teeth appears Fortunately, the lower canine teeth are
repositioned and restored, with or without to occur more frequently than missing lower often suitable abutments for resin-bonded
surgical alteration of the gingival margin lateral incisor teeth, it is debatable whether bridges and can usually provide adequate
positions, or alternatively, removed and lower central incisor teeth so commonly fail support for various bridge designs, even
prosthetically replaced, probably also with to develop. Given the likelihood that the those that replace all four incisors in a single
surgical alteration of the pontic sites. first tooth in each series (incisor, premolar structure.

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Conclusion
Peg-shaped and missing lateral incisor teeth
are common features for patients affected by
hypodontia. While improvements in dental
appearance may be a strong motivating factor
for these patients, providing dental treatment
to improve the clinical condition and achieve
an acceptable and stable outcome can be
complex and lengthy.
Consideration of various treatment
approaches is best done with the patient, by a
multidisciplinary team, who can determine the
Fig. 7 The lower dental arch in a hypodontia patient. The four lower incisor teeth are all
important personal, general and clinical factors
missing, causing almost complete failure of development of the alveolar ridge, with significant
that impact on the decision-making process.
labial and lingual concavities
The treatment outcome is likely to require
long-term orthodontic retention, regular
maintenance and periodic replacement of any
restorations placed.

Ethics declaration
The authors declare no conflicts of interest.
Guest Editor, Martin Ashley, was not involved in the
peer review process of this manuscript.

Author contributions
Sean Dolan, Gareth Calvert, Lynnsey Crane, Lee
Savarrio and Martin P. Ashley were all involved in the Fig. 8 Progressive failure of hard and soft tissue around dental implants used to replace
concept, writing, editing and reviewing of this paper.
missing lower incisor teeth. Note the upper lateral incisors were also replaced with dental
implant crowns, with long term stability

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